Left Lower Lobectomy for Sequestration: Pediatric Thoracic Surgery Part...

Patient is a 6-month-old with prenatal diagnosis of suspected cystic lung lesion, had CT scan in January at 2 weeks of life showing what appeared to be a solid-cystic lower lobe lesion, child has been asymptomatic

Intraoperative finding revealed the lesion to be an extralobar sequestration rather than the expected cystic lung lesion

CO₂ insufflation is used at a pressure of 8 with 2L flow through a single 5mm port, without achieving true lung isolation

Initial port placement is in the fifth intercostal space, approximately two-thirds of the distance between the tip of the scapula and the nipple, positioned directly over the fissure

Second 5mm port is placed in the anterior axillary line in as low an interspace as possible to provide room for manipulation and ligature placement

Using ports rather than simple stab wounds is preferred when using CO₂ insufflation because instruments will eventually leak around stab wounds with manipulation

Edematous sequestrations characteristically have a very narrow, small, tight pedicle

The edema in sequestrations is thought to result from the small pedicle size and abnormal lymphatic development through the pedicle

Careful dissection of the pedicle rather than mass ligation is preferred to identify what structures are present

The LigaSure LS1000 device is used for vessel sealing; while it takes longer than other methods (adding minutes to case time), it offers significant safety advantages

A 5mm trocar with 3mm reducer allows use of 3mm instruments while maintaining CO₂ seal; instruments should be lubricated with mineral oil to prevent sticking in the reducer

Pleural effusion associated with sequestrations results from either lymphatic or venous drainage issues, most likely lymphatic, with visible dilated lymphatic channels on the surface that weep fluid

The vascular pedicle in this case contained two separate vessels (artery and vein), each approximately 2mm in diameter

Once a good seal is visualized on a vessel after LigaSure application, the seal has never been observed to break open in the surgeon's experience

When extracting specimens through trocar sites, it is critical to avoid grasping normal lung and bringing it out through the trocar site

In a case of segmentectomy requiring reoperation for recurrence, adhesions were remarkably clean and not difficult to dissect

When completing a fissure during segmentectomy, fibrin glue is not routinely used unless there is a significant air leak observed

For 3mm port sites, if fascia is visible it should be closed; if not visible, skin can be closed with monocryl and dermabond

Chest tube is not necessary after sequestration resection; the chest can be evacuated through the trocar at the end of the procedure